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HomeMy WebLinkAboutApp-Permit-ComplianceNo. B Owt) C4 -6 55 I. elce C" T FEE COMMONWEALTH Of MASSAC USETTS L/ Board of Health, ) © Q�M , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(( Upgrade( ) Abandon( ) - ❑ Complete System XIiidividual Components Location (�� j Ro 'AS um rr-OLo Owner's Name (<gvllU C K O C.0VA1 Q Map/Parcel# --ao Address 30'?l 5CA5jrE1Z l%rC/tTto5 iZT Lot# Telephone# Installer's Name j-6 a PA . Designer's Name 1A Address153 (:Io Address Telephone# 5 Z 1 — Telephone# Type of Building Q�C Ci'1 �C3-Cid�� Ca d Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder Other - Tvpe of Building, No. of persons Showers O; Cafeteria,( ). Other Fixtures Design Flow (min. required) gpd Calculated design flow Plan: Date Number of sheets Title Description ofSoii(s) Soil Evaluator Form No. Name of Soil Evaluator Design flow provided gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS C 4kA) cG t 6 - t Ci�z�C"t l` -CM , The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees no ace Aie system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date No. �C`lU-C3J S FEE Board of Health, �AZAQ k rM , MA. CERTIFICATE OF COMPLIANCE Description of Work: Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired , Upgraded ( ), Abandoned by: O.A� u i nG C-aJ7°7CPAJK5< k8o P,144, C PE3,i at ROUM as UK1 r-r- 420 has been installe i accorda ce with the rovrissiions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. IX '1 7 , dated Wr/�./ /P- . Approved Design Flow '" (gpd) Installer Q1 Cw t U c- o�3�t:�A.5iss AP -go 81cWs0cz:D QxlPaV Designer:_ J Inspector: IQ' 1 -9-104 01 Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. " No.� '�O' iJ✓ !fit{` C--W I_DG FEE , , a 06 "2_ COMMONWEALTH Of MASSACHUSETTS ��(364 Board of Health, V A9 M 0 XMA MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) RepairA) Upgrade( ) Abandon( ) an individual sewage disposal system at 09 RoC+''t 6 alS V Fjrr r;�_o as described in. the application for Disposal System Construction Permit No. 4� dated r Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met:. Form 1255 Rev. 5/96 A.M. Stllkin Co. Chadesl0wn, MA Date 1/f J�7 Board of Health